Professional Documents
Culture Documents
Heberden's Nodes
Bouchard's Nodes
Accompany Heberden's nodes , Found at the PIP joint, Occur more often in women than men Increase in frequency
with age
4. Pathophysiology
a. stage one: microfracture of the articular surface
i. articular cartilage is worn away
ii. condyles of bones rub together: joint swells and is painful
iii. cartilage loses cushioning effect: joint friction develops
iv. prostaglandins may accelerate degenerative changes
b. stage two: bone condensation
i. erosion of cartilage
ii. cartilage may be digested by an enzyme in the synovial fluid
c. stage three: bone remodeling
i. matrix synthesis and cellular proliferation fail
ii. eventually the full thickness of articular cartilage is lost
iii. bone beneath cartilage hypertrophy and osteophytes form at joint
margins
iv. result: joint degenerates
5. Findings OSTEOARTHRITIS OF HIP/KNEE: SPECIFIC PHYSICAL FINDINGS
1. Hip
a. contracture in adduction and flexion
b. decrease in internal and external rotation
c. limb shortening
d. referred pain to the
i. knee
ii. groin
iii. thigh
2. Knee
a. decreased range of motion
b. flexion contracture
i. hip
ii. knee
c. varus deformity: bow legged appearance
d. valgus deformity: knock-kneed appearance
e. positive apprehension sign
i. push the patella laterally with the leg in full extension
ii. client will stop the examiner from pushing the patella further
6. Diagnostics
a. to rule out autoimmune disorders
i. sedimentation rate
ii. rheumatoid factor
iii. c-reactive protein
b. CBC
i. analyze before NSAID therapy
ii. within normal limits
c. kidney and liver
i. especially in older clients, analyze before starting NSAID therapy
ii. repeat every six months
d. purified protein derivative (PPD)
i. analyze before starting steroids
ii. clients testing positive for tuberculosis must receive INH at same
time as steroid.
e. antinuclear antigen (ANA) titer
i. may be lower in the elderly
ii. does not necessarily prove a connective-tissue disease
f. synovial fluid analysis distinguishes osteoarthritis from rheumatoid arthritis.
g. radiographs
i. taken in standing, weight-bearing condition
ii. shows the prime sign of OA: joint space narrowing
iii. x-ray does not necessarily reflect severity of disease
iv. joint loses space asymmetrically because cartilage narrows from
production of osteophytes or bone spurs
v. later stages may show bony ankylosis, spontaneous fusion
h. bone scans
i. radionuclide imaging
ii. shows skeletal distribution of osteoarthritis
iii. monitors complications of joint replacement surgery
i. MRI scans show the extent of joint destruction
j. computerized tomograms (CT) scans show cortical and cancellous bone density
7. Management: conservative treatment
a. education should cover
i. exercise patterns
ii. relaxation techniques
iii. nutritional assessment
iv. counseling about maintaining a normal weight
b. nutritional management - weight reduction
c. activity and rest management
i. preservation of joint motion through a balance of
1. rest (protection)
2. activity (rehabilitation)
ii. individualized activity rehabilitation program
iii. physical or occupational therapist may be helpful
iv. passive range of motion exercises (illustration )
v. active stretching
d. protection from further injury by splinting or bracing
8. Medication
a. aspirin - most often recommended
i. advantages: relatively safe and inexpensive
ii. disadvantage: GI problems may lead to ulcers and bleeding
b. nonsteroidal anti-inflammatory medications (NSAIDs)
i. reduce pain and inflammation
ii. inhibit prostaglandin formation
iii. may cause GI bleeding or gastric ulcers or cramping with diarrhea
c. adrenocorticosteroid injections
d. remissive agents
i. gold
ii. penicillamine (cuprimine)
iii. hydrochloroquinine (plaquenil)
9. Nonmedication assistance
a. assistive devices
i. canes
ii. walkers
b. non-traditional techniques
i. guided imagery - the use of one's imagination to acheve relaxation
and control
ii. therapeutic massage
iii. biofeedback
iv. hypnosis
v. relaxation techniques
10. Surgical management
a. arthrodesis
b. arthroplasty
c. osteotomy
d. total joint replacement
11. Home care considerations in arthritis
a. safety measures
i. no scatter rugs at home
ii. well-fitted, supportive shoes
iii. night light, handrails at stairs and bathtub or shower
iv. assistive devices
1. canes
2. walkers
3. elevated toilet seats
4. grab bars
5. handrails in stairways
v. splints and orthotic devices
b. management of surgical pain by patient controlled analgesia pumps
c. referral to agency and support group
2. Charcot joints (also called neuropathic joint disease)
6. Definition - multicausal degeneration and deformation of joint, usually ankle.
(illustration )
7. Etiology
a. diabetes mellitus leading to foot neuropathy
b. syringomyelia results in Charcot's joint of the shoulder
c. tertiary syphilis
d. peripheral neuropathies
e. spina bifida with myelomeningocele
f. leprosy
g. multiple sclerosis
h. long term intra-articular steroid injections
8. Findings
a. inspection: foot is everted, widened, and shorter than normal
b. examination
i. joint instability
ii. soft tissue swelling
iii. pain secondary to inflammation
9. Diagnostics
a. laboratory analysis of synovial fluid
i. fluid is non-inflammatory
ii. low protein content
iii. no hemorrhage noted
b. radiographs
i. chronic destructive arthritis of the foot
ii. severe destruction of the articular cartilage, subchondral sclerosis
iii. fragments of bone and cartilage in joint
10. Management
a. conservative treatment
i. protection from overuse/abuse
ii. braces and splints
b. surgical management: arthrodesis
i. treatment of choice for unstable joints
ii. fusion of the involved joint
11. Nursing interventions
a. expected outcome: preserve the joint
b. education can prevent further injury
c. protection of the joint
i. braces
ii. orthopedic shoes
d. prolonged immobilization
i. eight to 12 weeks to decrease swelling
ii. leads to minimal joint deformity and a functional painless foot
3. Chondromalacia patellae (also called patellofemoral arthralgia)
6. Definition: progressive, degenerative softening of the bone; follows a knee injury
(illustration )
7. Etiology
a. lateral subluxation of the patella (kneecap)
b. direct or repetitive trauma to the patella produces chondral fracture
c. underdevelopment of the quadriceps muscles
8. Findings
a. pain with flexed knee activities (poorly localized)
b. mild swelling
c. occasional episodes of buckling of the affected knee
d. minimal joint effusion
e. evidence of 'squinting kneecaps'
f. atrophy of quadriceps
g. inverted 'J' tracking of the patella in the final 30 degrees of extension
h. excessive quadriceps angle
i. positive apprehension sign
j. crepitation upon range of motion
9. Diagnostics
a. radiographs
i. anterior posterior (AP) and lateral views are not helpful
ii. sunrise views with the knee in 30 degrees, 60 degrees and 90 degrees
of flexion
b. bone Scans
c. MRI Scans
d. arthroscopy (see Orthopedic surgery)
10. Conservative management
a. progressive resistive exercises
i. quadriceps setting - isometric
ii. hamstrings - isotonic
b. medication: NSAIDs
c. nonmedication assistance: application of ice or moist heat
d. activity restriction
11. Surgical management
a. indicated if findings remain after six months of conservative treatment
b. arthroscopy (see Orthopedic Surgery section that follows)
c. arthrotomy
i. realignment of proximal and/or distal soft tissue
ii. tibial tubercle elevation
iii. patellectomy
12. Nursing interventions (see previous Osteoarthritis section)
2. Inflammatory Disorders
1. Rheumatoid arthritis (RA)
6. Definition - chronic systemic inflammatory disease of the connective tissue
7. Findings
a. starts in feet and hands, gradually destroys these peripheral joints
b. affects diarthroidial joints
c. bilateral involvement
8. Etiology
a. cause is not fully understood
b. rheumatoid arthritis is an autoimmune disorder
c. genetic tendency; but may involve bacteria, or viruses
d. may affect the connective tissue of the lungs, heart, kidneys, or skin
9. Incidence
a. two to three times more common in women than in men
b. strikes between the ages of 20 and 50 years of age
10. Pathophysiology
a. synovitis immune complexes initiate inflammatory response
i. IgB antibodies are formed
ii. rheumatoid factor (RF)
1. pannus formation
2. destruction of subchondral bone
3. present in 85 to 90% of all cases
4. worsens the inflammatory response - can go on indefinitely
5. irreversible - will lead to ankylosis of joint
11. Findings
a. in early RA joints will be
i. painful, stiff
ii. warm, red, swollen at capsules and soft tissues
iii. incapable of full range of motion
b. in late RA, joints will show
i. bony ankylosis
ii. destruction of joint - reactive hyperplasia
iii. adhesions
iv. inflammation and effusion that will be
1. symmetrical
2. polyarticular
c. general signs
i. fatigue
ii. loss of appetite and weight
iii. enlarged lymph glands (illustration )
d. rheumatic nodules
i. in 20% of cases
ii. firm, oval, nontender masses under the skin
iii. presence indicates poor prognosis
e. physical assessment should also include
i. accurate patient history - history may include
1. malaise
2. fatigue
3. weakness
4. loss of appetite and weight
5. enlarged lymph glands
6. Raynaud's syndrome
ii. examination may reveal deformities
1. ulnar deviation
2. deformed hands: swan neck/boutonniere
f. neurological examination
i. foot drop
ii. evidence of spinal cord compression
12. Diagnostics
a. laboratory analysis
i. elevated ESR
ii. decreased RBC
iii. positive C-reactive protein
iv. positive antinuclear antibody in 20% of cases
v. positive rheumatoid factor (RF)
b. radiographic studies
i. bony erosion
ii. decreased joint spaces
iii. fusion of joint
c. aspiration of synovial fluid; analysis shows
i. cloudy appearance
ii. more white blood cells than normal
13. Management
a. (see previous Osteoarthritis section)
b. psychological support
c. splinting: resting, corrective, or fixation
2. Systemic lupus erythematosus (SLE)
6. Definition: chronic, systemic, inflammatory disease of the collagen tissues (illustration
)
7. Etiology unknown
a. most cases are women
b. African Americans, Hispanics, Asians, and Native Americans are two to three
times as likely as whites to have lupus
c. antigen stimulates antibodies, which form soluble immune complexes,
deposited in tissues; number of T suppressor cells dwindles. (illustration )
d. immune complex inflames tissue; inflammation creates findings
i. the intensity and location of the inflammation reflects findings and
organs involved.
ii. clients with central nervous system or renal involvement have poorer
prognosis
8. Findings: SLE is present if client has four or more of these:
a. arthritis: characterized by swelling, tenderness and effusion; involving two or
more peripheral joints
b. malar rash: characteristic butterfly rash over cheeks and nose
c. discoid lupus skin lesions
d. photosensitivity
e. oral ulcers
f. serositis: pleuritis
g. renal disorder: persistent proteinuria
h. neurologic disorder: seizures or psychosis in the absence of drugs or pathology
i. hematologic disorder: hemolytic anemia with reticulocytosis or leukopenia
j. immunologic disorder: positive LE (lupus erythematosus) cell preparation or
anti-DNA or anti-Sm or false positive serologic test for syphilis
k. antinuclear antibody: abnormal titer of antinuclear antibody by
immunofluorescence or equivalent assay
l. positive LE cell reaction
9. Management
a. expected outcomes
i. control system involvement and symptoms
ii. induce remission
b. prevent bad effects of therapy
c. recognize flare-ups promptly
d. medical
i. salicylates
ii. nonsteroidal anti-inflammatory agents (NSAIDS)
iii. corticosteroids
iv. anti-infectives
e. antineoplastics
10. Nursing care
a. pain management strategies
b. strategies to combat weight loss
c. emotional support
3. Gout (illustration )
6. Definition
a. monoarticular asymmetrical arthritis
b. characterized by hyperuricemia
7. Etiology
a. primarily affects men
b. peak incidence 40 to 60 years of age
c. familial tendency
d. abnormal purine metabolism or excessive purine intake results in formation of
uric acid crystals which are deposited in the joints and connective tissue.
e. deposits are most often found in the metatarsophalangeal joint of the great toe
or in the ankle.
8. Findings
a. tight, reddened skin over the inflamed joint
b. elevated temperature
c. edema of the involved area
d. hyperuricemia
e. acute attacks commonly begin at night and last three to five days
f. gout attacks may follow trauma, diuretics, increased alcohol consumption, a
high purine diet, stress (both psychological and physical) or suddenly stopping
of maintenance medications
g. warning signs of flare-up include the exacerbation of previous findings or the
development of a new one
h. systemic manifestations may include fever, renal disease, tophus
9. Diagnostics: lab tests find -
a. increased urinary uric acid following a purine restricted diet
b. hyperuricemia
10. Management
a. expected outcomes: control symptoms; prevent attacks
b. medical
i. NSAIDs
ii. colchicine (used when NSAIDs are contraindicated) - enhances the
excretion of uric acid
iii. to prevent flareups: antihyperuricemic agents such as allopurinol
(lopurin) or probenecid (benemid) - minimize the production of uric
acid
iv. heat or cold therapy
c. dietary
i. avoid purine foods such as meats, organ meats, shellfish, sardines,
anchovies, yeast, legumes
ii. control weight
iii. drink less alcohol - all types
11. Nursing care
a. pain management strategies
b. elevate the affected limb; provide bed rest and immobilize joint
c. avoid pressure or touching of bed clothing on affected joint
d. reinforce dietary management and weight control
e. administer anti-gout medications as ordered
f. increase fluid intake to prevent renal calculi (kidney stones)
3. Metabolic Bone Disorders
1. Osteomalacia
6. Definition - delayed mineralization; resulting bone is softer and weaker
7. Pathophysiology - similar to rickets
a. bones have too little calcium and phosphorus
b. vitamin D deficiency; possibly inadequate exposure to sunlight
i. less serum calcium than normal
ii. more parathyroid hormone
iii. more renal phosphorus clearance
8. Findings
a. accurate client history includes:
i. generalized muscle and skeletal pain in hips
ii. similar pain in low back
b. physical examination
i. gait
1. client unwilling to walk
2. wide stance
3. waddling gait
ii. muscle weakness
iii. bones
1. deformities of weight-bearing bones
2. scoliotic or kyphotic deformities of the spine
3. bones break easily
9. Diagnostic testing
a. radiographic findings
i. generalized demineralization
ii. pseudo fractures
iii. bending deformities
b. laboratory studies
i. decreased serum calcium
ii. decreased serum phosphorus
iii. alkaline phosphatase level is moderately elevated
10. Management
a. calcium gluconate
b. vitamin D daily until signs of healing take place
c. diet high in protein
d. ultraviolet radiation therapy
2. Osteoporosis (illustration )
6. Definition
a. multifactorial disease results in
i. reduced bone mass
ii. loss of bone strength
iii. increased likelihood of fracture
b. types
i. type one osteoporosis (estrogen related)
ii. type two osteoporosis (related to old age)
7. Etiology/epidemiology
a. most common metabolic disease of bone
i. affects an estimated 25 million Americans
ii. contributor of 50% of all adult fractures
b. onset is insidious
c. women affected twice as often as men before the age of 70
d. skeletal changes result from the aging process
e. bone loss due to
i. immobilization
ii. lack of gravitational stress
8. Factors related to osteoporotic fractures
a. premature menopause
b. hyperthyroidism increases bone turnover and remodeling
c. hyperparathyroidism
a. total hip replacement (hip arthroplasty) is the replacement of both articular surfaces of the hip joint, the
acetabular socket and the femoral head and neck.
b. hemiarthroplasty of the hip is the replacement of one of the articular surfaces, usually the femoral head and
neck.
2. Surgical and immediate postoperative care
a. in first 24 hours, expect wound to drain blood and fluid up to 500ml.
b. by 48 hours, wound drainage should be minimal
c. clients may require transfusions (autologous is preferred) due to blood loss during surgery.
d. best pain management is patient controlled analgesia (PCA) for the first 48 hours, advancing to non-narcotic
oral analgesics by the fourth or fifth postoperative day.
e. monitor for signs of deep venous thrombosis (DVT) and pulmonary embolism (PE) or fat embolism
f. monitor neurovascular status of affected limb; color, temperature, presence of pulses.
3. Postoperative complications ORTHOPEDIC COMPLICATIONS
4. Nursing interventions
a. an abduction device is used during the first postoperative week while the client is in bed or sitting in a chair
b. to keep abduction device in place, turn client by logrolling
c. to prevent flexion of the hip, use fracture bedpan
d. client teaching
I. use of assistive devices; crutches, walker, raised toilet seat
II. methods to prevent dislocation
III. can resume sexual activity when suture line heals. To avoid flexion of
hip, client should be in dependent position for three to six months
B. Total knee replacement
1. Indications for surgery
a. osteoarthritis
b. rheumatoid arthritis
c. trauma
2. Surgical modalities
a. metal or acrylic prosthesis, hinged or semiconstrained
b. choice of prosthesis depends on the strength of surrounding ligaments to provide joint stability
3. Postoperative complications ORTHOPEDIC COMPLICATIONS
1. Toes and portion of the foot - usually as a result of trauma or infection. Causes minor changes in gait or
balance
2. Syme: disarticulation of ankle; stump can bear full weight, with prosthesis
3. Below knee (BK) - preserves knee joint which facilitates use of prosthesis
4. Knee disarticulation - at level of knee joint
5. Above knee (AK) - measures undertaken to provide as much length to limb as possible
6. Hip disarticulation - most often performed due to malignancy. Client cannot walk with prosthesis.
7. Below elbow (BE) - preserves elbow joint, thus eases use of prosthesis
8. Above elbow (AE) - measures undertaken to provide as much length to limb as possible
9. Staged amputation - used for infection. Guillotine amputation to remove infectious and necrotic tissue is
performed. After intensive antibiotic therapy, a second operation is performed for skin closure.
A. The Ilizarov device is a specialized type of external fixator used for non-union fractures and limb lengthening
needed due to congenital deformities.
B. Tension wires are inserted into the bone and then attached to rings outside the body. These rings are joined by
telescoping rods attached to a rigid frame. Daily adjustment of the rods causes the wires to turn, which
stimulates bone formation.
C. Ilizarov device lengthens limbs about one cm per month.
D. Before discharge, teach clients
1. To care for pin
2. To adjust rod
E. Clients may have the device on for several months.
a. Indication: the device will stabilize fracture with soft tissue injury like crush fractures
b. Procedure: fracture aligned and immobilized by pins of Kirschner wires inserted in the
bone and attached to a rigid frame outside the body
c. Nursing interventions
A. monitor neurovascular status every two hours
B. elevate extremity to reduce edema
C. assess pin insertion sites for infection: erythema, drainage and increased
warmth
D. isometric and active exercises as prescribed
E. non-weight bearing ambulation depends on soft tissue injury
F. discharge teaching
A. ambulation with assistive device (crutches, walker)
B. care of pin site
C. extremity is repositioned by lifting frame instead of extremity
I. After hip replacements, pulmonary embolism may occur even without thrombosis in foot or leg.
J. Clients should sit in a straight, high chair; use a raised toilet seat; and never cross their legs.
K. In hip or knee replacement, clients will need assistive devices for walking until muscle tone strengthens and
they can walk without pain.
L. After an amputation, the home must be assessed for any modifications needed to ensure safety.
M. Some clients will need transportation to continue rehabilitation.
N. Amputee support groups can help clients and family.
O. After arthroscopy, outpatient rehab may be prescribed depending on procedure; health care provider may
prescribe knee immobilizer.
P. External Fixator - If possible, prepare the client preoperatively to reduce anxiety. Device looks clumsy, but
patient should be reassured that discomfort is minimal.
Q. After a hip pinning or femoral-head prosthesis, caution client not to force hip into more than 90 degree of
flexion, into adduction or internal rotation which will cause dislocation and severe pain and this would be a
nursing emergency.
R. Caution clients with a new prosthesis not to use any substances such as lotions, powders etc. unless
prescribed by the health care provider.
S. Osteoporosis cannot be detected by conventional X-ray until more that 30% of bone calcium is lost.
T. Foods high in calcium include milk, cheeses, yogurt, turnip greens, cottage cheese, sardines, and spinach.
U. When performing a musculoskeletal assessment on a client with Paget's disease, note the size and shape of
the skull. The skulls of these clients will be soft, thick and enlarged.
V. Clients at high risk for acute osteomyelitis are: elderly, diabetics, and clients with peripheral vascular disease.
W. When clients receive corticosteroids long-term, evaluate them continually for side effects.
X. Immunosuppressed clients should avoid contact with persons who have infections.
Y. Steroids may mask the signs of infections, so client should promptly report slightest change in temperature or
other complaints.
Z. Photosensitive clients should avoid the sun, limit outdoor activities during peak sun hours and wear sun
block.